SECTOR PERSPECTIVES

HE ALTHC ARE
1 2020 AND
BE YON D

2 TU RNI NG
TO TECH

3 STRONG ER
TOGE T HER

4 DOING MO RE
FOR LESS

5 PEOPLE
POW E R
A I B ( G B ) S E C TO R P E R S P E C T I V E S : H E A LT H C A R E
Welcome to Healthcare Perspectives, Allied
Irish Bank (GB)’s new review of the UK healthcare
sector. We are delighted to share our perspectives on the
opportunities and challenges facing the sector and hope
you will benefit from our insights.
We welcome the Rt Hon Professor Paul Burstow,
Minister of State for Care in the 2010-2015 coalition
government, who shares his own personal view of the
importance of focussing on the needs of the patient,
service user and carer.
AIB (GB) has been working in partnership with the UK
healthcare sector for more than 20 years. Over the course
of these two decades, the delivery of healthcare has been
transformed, but our core principles have remained
unchanged, with a commitment to developing long-term
relationships through the quality of our customer service.
Our understanding of the sector has its roots in
these deep client relationships, which evolve as their
businesses grow organically, through acquisition or
through IPOs. Our experience informs the way we help
our clients navigate the changing currents of healthcare.
The healthcare industry faces unique challenges, as
investors seek a reasonable return on their investment
while maintaining a focus on the quality of the care
they provide, as well as the safety of their service
users. Our review below explores these issues in depth:
2020 and Beyond looks at the opportunities for innovation
in the healthcare sector over the next few years as
providers harness the benefits of new personalised care
technologies for better outcomes and affordability.
Stronger Together presents a vision of a new collaborative
approach between health and social care, and between
the public and private sectors, to deliver affordable,
high-quality care in hospital and in the community.
Doing More for Less explains that there are critical
learnings for healthcare from other sectors in the
application of new strategies and processes, including
digital technologies, to deliver patient care that is safe
and sustainable in an era of budgetary constraints.
3
foreword
BY M A R G U E R I T E M U LV E Y
HE A D OF HE A LTHCA RE
AT AIB (GB)
People Power pays tribute to the
dedication of frontline staff, and
explains how companies must invest
in employee engagement to nurture
tomorrow’s leaders of change.
AIB (GB) continues to establish new
customer relationships, particularly
in social care. We value established
businesses with strong, experienced
management teams and a solid trading
record, especially those with a focus
on care quality evidenced through
outstanding CQC or Ofsted inspections. We
are able to expedite our lending decisions
quickly, to help investors capitalise on
opportunities when they arise.
We hope that Healthcare Perspectives
will make you want to learn more about
our unique healthcare offering. We
have built up an impressive portfolio of
reputable clients – from SMEs to large
corporations – who have benefitted from
the advice and support of our dedicated
team. If healthcare is your business, we
look forward to hearing from you.
4 AIB (GB) SECTOR PERSPECTIVES

2020 and
beyond
Despite being under increasing pressure, the
NHS can look forward with optimism, with
proposed changes leading to a radical overhaul
of the way healthcare is managed

These are critical times for the UK health sector.

The changes that are likely to take place within the
NHS over the next five years or so are probably more
significant than anything that has happened to it since it
was founded in 1948.
The health service is under greater than ever pressure.
An ageing population and a big increase in the number of
people living with long-term conditions, such as diabetes
and heart disease, means demand for care provided by
GPs, hospitals and community health teams is rising
significantly. Long-term conditions already account for
70 per cent of the NHS budget and this is set to increase.
At the same time, financial constraints are unlikely
to ease. The UK government has committed more funds
for the NHS, linked to gains in productivity through a
transformation in the way the health service works. Amid
the economic uncertainty that has followed the UK’s
decision to leave the European Union, it has become clear
that this financial settlement is unlikely to be renegotiated.
Shaping the future
In 2014, Simon Stevens, chief executive of
the NHS, published his blueprint for the
new NHS, the NHS Five-Year Forward
View. Although this notionally established
the direction of travel for the health
service through to 2020, the reality is that
the changes proposed by Mr Stevens are
intended to shape the NHS through the
next decade and probably beyond.
At the heart of the Stevens plan is
a radical upgrade in prevention and
H E A LT H C A R E 5

public health. This requires hard-hitting

national action on obesity, smoking, “Emergency care services
alcohol and other major health risks.
The ambition is to develop and support
will be redesigned to
new workplace incentives to promote integrate between A&E
employee health and cut sickness-
related unemployment. There will be departments, GP out-of-
stronger public health-related powers for
local government and elected mayors.
hours services, urgent
Patients will gain greater control of their care centres, NHS 111 and
own care, including the option of shared
budgets combining health and social care. ambulance services”
6 AIB (GB) SECTOR PERSPECTIVES
Care home
residents are
40-50%
more likely to have an
emergency admission /
A&E attendance than the
general population of
2020-21 over 75s
NHS funding
gap forecast
Source: Deloitte Centre for Health Connections 2015
The 1.4 million full-time unpaid carers in England will
get new support, and the NHS will become a partner with
voluntary organisations and local communities.
The NHS has promised decisive steps to break down
the barriers in how care is provided between family
doctors and hospitals, between physical and mental
health, and between health and social care. The
future will see more care delivered in the community,
with some services in specialist centres, organised to
support people with multiple health conditions, not
just single diseases.
Forming partnerships
Across the NHS, urgent and emergency care services
will be redesigned to integrate between A&E
departments, GP out-of-hours services, urgent care
centres, NHS 111 and ambulance services. Smaller
hospitals will have new options to help them remain
viable, including forming partnerships with other
hospitals further afield and partnering
with specialist hospitals to provide more
local services. Midwives will have new
options when it comes to taking charge of
the maternity services they offer, and the
NHS will provide more support for frail
older people living in care homes.
England is too diverse for a one-size-
fits-all care model. In some devolved
areas, such as Manchester, budgets
and responsibility for health and
social care will be transferred to local
authorities, who will develop models
that suit their population. Elsewhere,
local health communities will be
encouraged to choose from a small
number of radical new care-delivery
options, and then given the resources
and support to implement them. This
approach could, potentially, accelerate
the fragmentation of a countrywide
health service, which has already seen
new models of care emerge in Wales,
Scotland and Northern Ireland.
Technology will play a crucial role
in the evolution of the health service
into the next decade. After a number of
costly and ignominious false starts, there
is a determination across the NHS to
harness the power of digital technology
to improve delivery of care while gaining
operational efficiencies. The tech
industry has enjoyed huge success in
creating consumer health products, but
these are not comprehensively linked
to the health and social care sector. The
new National Information Board hopes
to put this right by bringing together
organisations from across the NHS,
public health, clinical science, social
care and local government and public
H E A LT H C A R E 7

Technology to
look out for in 2017
Robotic nurse assistants –
Automation is reaching deeper
into healthcare, with the unveiling
of a robot named RIBA (Robot for
Interactive Body Assistance, pictured
right) – the first robot that can lift up
or set down a patient from or to a bed
or a wheelchair, in the same way a
healthcare assistant would. RIBA has
strong, human-like arms and tactile
guidance methods thanks to its high-
accuracy tactile sensors.

Smart walking stick – French walking

stick makers Fayet has created a next-
generation walking stick that monitors its
users as they move and alerts caretakers
if they have a fall. It is also fitted with
software that over time learns its owners’
walking habits and can send a message
to relatives and healthcare professionals if
they change dramatically.

Lightbulbs that disinfect – Hospitals

“Technology will play a
are excited by the development of
technology that uses visible light to
crucial role in the evolution
continuously disinfect the environment of the health service into
and bolster infection-prevention efforts.
The light reflects off walls and surfaces
the next decade”
and penetrates harmful microorganisms.

Long-lasting batteries – New representatives to develop systems collaboratively,

technologies are emerging that will provide
longer-lasting batteries that are quick
to charge, transforming the efficiency
of medical devices from wearables to
pacemakers. Aluminium-ion batteries,
micro supercapacitors, foam batteries
and even skin power (which harvests the
current caused by friction on skin and
clothes) are all set to become mainstream.
instead of imposing them centrally.
So, against a challenging background for the NHS and
social care, there are opportunities for the healthcare
industry in developing products and services that
support Stevens’ vision of an affordable and sustainable
health service. Whether it is helping patients manage
their own care at home, or helping care professionals
navigate their way across the increasingly complex
health landscape, the outlook is bright.
8 AIB (GB) SECTOR PERSPECTIVES
Turning
to tech
How can we make efficient use of technology
in the care sector, asks the Rt Hon Professor
Paul Burstow, Minister of State for Care in
the 2010-2015 coalition government
Across the four home nations, both the NHS
and local government are facing huge financial and
workforce pressures. In October 2016, the Care Quality
Commission warned that the system was approaching
a tipping point, and the Chancellor’s Autumn Statement
offered no comfort.
Combined spending on NHS and social care accounts
for around 9.9 per cent of the nation’s wealth – not the
highest figure among OECD nations but far from the
lowest, either.
Successive governments have failed to prioritise
social care, and complex arrangements for the funding
of adult social care in England have left the system
chronically underfunded. The result is a healthcare
system that’s running hot, with large numbers of people
stuck in expensive hospital beds. At the same time,
57 per cent of councils in England recently reported
that home care providers had handed back contracts
because they could not make them pay.
Most of the care estate is privately
owned. Return on investment matters
and, as the CQC reported in its State of
Care report last year, no new nursing
beds have been added in the past year. In
a recent survey of councils, 62% reported
a reduction in the number of care home
places in the past six months. Just beneath
the radar, the sector is withdrawing from
state-funded care – and hard-to-replace
capacity is being lost.
Embracing technology
It’s clear that government is not yet
convinced there’s a need to boost
funding for care. And just asking for
more money isn’t enough; there has to be
an offer of modernisation too.
Making better use of technology
ought to be part of the offer. I recently
hosted for the TSA (Telecare Services
Association) a round table of local digital
leaders with proven track records of
incorporating technology solutions into
health and care services. They told their
stories of transforming services and
turning the use of technology into the
new “business as usual”.
The common competencies that
marked out the contributors were
business intelligence and analytics,
using the data to dive deep into their
business processes to understand
where the opportunities are to improve
practice-level decision-making, increase
productivity and deliver better results for
people. These skills are in short supply
and could be a serious obstacle to the
rapid progress that governments in all
four nations are seeking.
The message that came loud and clear
from participants was to not be dazzled
by the kit, and to be “tech agnostic”.
H E A LT H C A R E 9

Effect of a mobile working

solution for community nurses

60% Time spent

on paper
work

Face time
with patients
29% extra patients
seen daily

Outcomes from implementation of

telemedicine hubs across 210 care homes

35% 53% 59%

Hospital admissions Use of A&E Hospital bed days

Source: Deloitte Centre for Health Connections 2015

Instead of focusing on technology, focus
on meeting the needs of the patient,
service user and carer; technology is the
enabler to improve the quality of life of
the patient, service user and carer.
This needs robust benefits realisation
to provide councils and NHS finance
directors with the assurance they need
that costs are being reduced or avoided.
Benefit realisation is equally vital
when it comes to information sharing
within and across health, social care
and housing. Showing how information
can be used to develop a sophisticated
picture of population health needs
is allowing a more anticipatory and
preventative approach to take shape.
To make a reality of technology-
enabled care services (TECS), not only do
commissioners and service planners have to be bold and
work differently, so, too, do technology suppliers. The
industry offer must include a willingness to collaborate,
to source the business intelligence and analytics
capacity that’s vital to effective service redesign, and to
support robust benefit realisation.
A twin-track approach – arguing the case for
investing in care services, while redesigning services to
deliver optimum results and increased productivity –
has the best chance of success.
“Instead of focusing on
technology, focus on meeting
the needs of the patient,
service user and carer”
10
Stronger
together
Successful integration of health and social care will
deliver a more efficient, more targeted offering,
reshaping the delivery of care across the country
In England, healthcare and social care have
evolved as distinct systems. They may often provide
care to the same people, working side by side and
sometimes even sharing facilities. But they are separate
organisations, with different cultures, funding,
leadership and responsibilities.
The NHS is the responsibility of central government,
while social care is the responsibility of local
authorities, with funding raised locally as well as
centrally to cover the cost of providing care to the most
vulnerable in the community. A further difference is
the high level of private provision of social care, from
residential care homes for the elderly to community-
based support for mental health and wellbeing.
There is a growing convergence of opinion that these
distinct models are no longer appropriate, and that greater
integration of health and social care is essential in order
to create services that are sustainable and provide high-
quality care. One of the main reasons for this concerns
the ageing population and the increase in the number
of people living with long-term conditions. Their care
requires greater co-ordination between different services,
from GPs and health visitors to hospital specialists.
AIB (GB) SECTOR PERSPECTIVES
Also, there must be a greater emphasis
on community-based prevention, to
reduce the number of patients who
require medical treatment because of a
deterioration in their condition.
Deeper collaboration
Previous attempts to bring health and
social care closer together nationally have
stalled. But there is a new sense of purpose
about the need for deeper collaboration,
and the government is encouraging new
models of care to be developed locally.
A leading example of this is taking place
in Greater Manchester, which became
the first English region to gain control of
health spending. The £6bn annual health
and social care budget will be managed
by councils and health groups as part of
an extension of devolved powers. The
Greater Manchester Health and Social
Care Strategic Partnership will now make
decisions on how to target specific health
issues in the region, and integrating health
and social care services is expected to ease
pressure on hospitals in the region.
Devolution of responsibilities for
healthcare in Manchester is a significant
step towards one of the main aspirations
of the NHS Five-Year Forward View,
which is to break down the barriers
between health and social care. One
new option will be to encourage groups
of GPs to combine with nurses, other
community health services, hospital
specialists and perhaps mental health
and social care to create integrated
out-of-hospital care, to be known as
multispecialty community providers.
Early versions of these models are already
emerging in different parts of the country,
and are likely to play a key role in
reshaping the delivery of care in England.
H E A LT H C A R E
C A S E S T U DY:
B&M Care
For over 40 years B&M Care has been
building a brand based on quality
B&M Care is a family-run, privately owned
company that operates private residential and
respite care homes for the elderly in Hertfordshire,
Buckinghamshire, Berkshire and Northamptonshire.
Founded by Bill Hughes, who purchased his first nursing
home in 1975, the group now runs 26 homes, providing
care for about 1,200 people.
Hughes, who is chairman of B&M, says that he did
not expect to build such a substantial business when he
purchased that first care home more than four decades
ago. “We didn’t set out to create a major group, and we
have taken a long time to get where we are. We have
built the business one home at a time – buying sites,
then building and opening properties. We offer a very
good specification, and have chosen sites within a
50-mile radius, so it’s possible for me to visit any of our
homes in a day.”
B&M homes offer long-stay and short-stay, person-
centred care, including accredited, specialist dementia-
care environments – and the company’s approach to
dementia care supports the National Dementia Strategy.
“The care home sector has changed considerably
since we opened our first home,” says Hughes. “But
what we do now is, in essence, no different from what
we did in 1975. It’s about providing high-quality care
and creating an environment where our residents and
their families can feel at home.”
B&M has been a valued Allied Irish Bank (GB) client
since Bill acquired his first care home back in 1975. “Back
then, they understood what we were trying to do, and were
enthusiastic and supportive from the first day. As we have
grown, AIB (GB) has been behind us all the way. If it hadn’t
been for AIB (GB), there might not have been a B&M.
11
“Our success is based on what has
developed into a very good relationship
over the years. AIB (GB) has strong
expertise in the healthcare sector and
understands the business of care homes,”
says Hughes. The ethos and values of a
family-run business helps B&M to recruit
and retain the best care staff, despite
operating in an area of high employment
and skills shortages.
Despite the uncertain outlook for
the care homes sector in England, B&M
continues to go from strength to strength.
The company’s newest development
is Bury Lodge Care Home in Knotty
Green, Beaconsfield, which opened in
April 2016. New care homes are being
developed at Crowthorne, Kings Langley
and Hoddesdon.
“Our business model is simple,” says
Hughes. “We keep a tight control of our
development costs and profit margins. And
we provide high-quality care, which is
what families want for their loved ones.”
“What we do now is
no different from
what we did in 1975.
It’s about providing
high quality care
and creating an
environment where
our residents and
their families can
feel at home”
12
£
Doing more
for less
During these lean times, adopting simple
measures to save excess spending is vital
– but patient care must remain unaffected
Healthcare providers face a universal
challenge: how to do more for less. Demand is rising
– driven by age and the prevalence of long-term
conditions – but budgets are being squeezed and are
unlikely to ever recover, in real terms, to the levels of
a generation ago.
Cutting costs doesn’t have to mean reducing
patient care, however. Healthcare is generally behind
manufacturing and other service industries in applying
modern management techniques to create processes
that are safer and more convenient for service users,
and more focused on eliminating waste. Healthcare
has also fallen behind in the use of digital technology
to harness information that can be used to redesign
care processes, to make them safer and more efficient.
A review of efficiency and productivity in NHS
hospitals, carried out by Lord Carter and published in
2016, identified a number of measures that could save
hospitals £5bn a year, which could be reinvested in
patient care.
AIB (GB) SECTOR PERSPECTIVES
His review found unwarranted
variation in running costs, sickness
absence, infection rates and prices
paid for supplies and services. Lord
Carter estimated that a one per cent
improvement in staff productivity could
save the NHS £280m a year, which
equates to hospitals using new working
methods that would save every member
of staff five minutes on an eight-hour
shift. Lord Carter’s recommendations
for change spanned many areas beyond
frontline patient care, including
procurement, inefficient use of floor
space, delayed transfers of care, and
collaboration with neighbouring
healthcare providers to share services
and resource.
The National Academy of Medicine
in the US has identified six areas in
which excess costs accrue: unnecessary
services; inefficiently delivered
services; prices that are too high;
excess administrative costs; fraud;
missed prevention opportunities.
Each of these areas offers significant
scope for reducing costs and improving
efficiency, as well as providing
opportunities to improve the quality
of care rather than curtailing services.
For example, organisations should
consider how they can reduce the
use of antibiotics and non-evidence-
based imaging procedures. Hospitals
must aim to prevent costly, unplanned
re-admissions, and make greater use
of digital medical records to optimise
preventive screenings and vaccinations.
Palliative care is increasingly
demonstrating that attention to
patients’ preferences and priorities can
dramatically improve the patient and
family experience at a lower cost.
H E A LT H C A R E 13

Technology enables stunning

clinical interventions, remote human
Acute NHS interactions and physiological
trusts spend

£55.6 £33.9
monitoring, and previously
unobtainable collection and analysis
of data. But the growth of technology is
billion billion also part of the burgeoning complexity
every year of which goes of modern healthcare, and the trend
on staffing
towards more journals, more data,
more clinical interventions, more drugs
– and more complex organisations
delivering care. This complexity
requires new approaches: from
redesigning the temporal and physical
flow of patient visits to rethinking
continuing education and real-time
decision support.
Both the NHS and private healthcare
suppliers face the challenge of how to
implement reform effectively. While
their processes will be dramatically
different, the crux of their reform is
the same: supporting their workforces
through the changes, acknowledging
the difficulties they face and equipping
them to do their jobs.

£2.0
billion
£0.8
billion
£0.2
billion
£0.7
billion
£1.0
billion
£0.3
billion
£5.0
billion “The key for
implementing
Optimised use of
clinical workforce

Hospital pharmacy

(back office) costs

and medicines
optimisation

Diagnostics –
pathology & radiology

Procurement

Estates and facilities

management

Corporate and
administration

Total opportunity

reform lies
with supporting
the workforce
A review of efficiency and productivity in NHS hospitals, carried
out by Lord Carter and published in 2016, identified a number of
through these
measures that could save hospitals £5 billion a year, which could
be reinvested in patient care. changes”
Source: Department of Health, 2016
14
People power
The key to delivering the best healthcare is having a
fully engaged workforce, so invest in your staff and
watch them become leaders of change
Healthcare is a people business. The quality of care
that patients receive depends first and foremost on the skill
and dedication of staff. Highly engaged employees who are
committed to their organisations and involved in their roles
are more likely to bring their heart and soul to work, to use
their initiative and to collaborate effectively with others.
There is overwhelming evidence to show that engaged
staff really do deliver better healthcare. The NHS providers
with high levels of staff engagement (as measured in
the annual NHS staff survey) tend to have lower levels
of patient mortality, make better use of resources and
deliver stronger financial performance. Engaged staff
are more likely to have the emotional resources to show
empathy and compassion, despite the pressures they work
under. Trusts with more engaged staff tend to have higher
patient satisfaction, with more patients reporting that they
were treated with dignity and respect.
Yet the question of how to create an engaged workforce
is often left unanswered by senior leaders, who are more
preoccupied with the day-to-day challenges of their
organisation. While levels of staff engagement have risen
across the healthcare sector over the past few years, the
disparities between organisations are wider than ever.
Those trusts with the lowest levels of staff engagement
are falling further behind the leaders.
AIB (GB) SECTOR PERSPECTIVES
At a time of profound change across
health and social care, the most successful
providers are giving their staff the tools
and resources to lead transformation
from the front line. Rather than calling in
external experts to redesign services, they
are using these resources to help frontline
staff embed quality improvement. By
investing in and empowering their staff,
these organisations are unleashing their
employees’ enthusiasm and creativity
to improve how they work, creating a
constituency of leaders of change, rather
than stubborn opponents of change.
Employees make the best ambassadors
for any organisation, and, in a culture in
which the credibility of messages from top
executives is under significant scrutiny,
word-of-mouth and social media channels
among healthcare employees are playing a
key role in decision making for jobseekers.
Constructive internal stakeholder
engagement must be top of the agenda for
any board that hopes to attract and retain
the best staff.
The King’s Fund, the health and social care
think tank, has identified six building blocks
for a highly engaged workforce:
•D
 evelop a compelling,
shared strategic direction
•B
 uild collective and
distributed leadership
•A
 dopt supportive and inclusive
leadership styles
•G
 ive staff the tools to
lead service transformation
•E
 stablish a culture based
on integrity and trust
•P
 lace staff engagement
firmly on the agenda
 To speak with a bank that can help

you grow your business, call

+44 (0)207 090 7127

or email

marguerite.a.mulvey@aib.ie

aibgb.co.uk

Allied Irish Bank (GB) and Allied Irish Bank (GB) Savings Direct are trademarks used under license by
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